Children with palliative care needs in Papua New Guinea, and perspectives from their parents and health care workers: a qualitative study.

INTRODUCTION: The World Health Organisation defines paediatric palliative care (PPC) as caring for the child's body, mind, and spirit, and giving support to the family. In life-limiting conditions it is important that palliative support can be provided even when curative attempts are being utilised. In Papua New Guinea, as in other low- and middle-income countries there is a lack of services and training on PPC. This study aims to describe the characteristics of children with palliative care needs and to assess the perspectives of their parents and health care workers. METHODS: A descriptive qualitative study was carried out over 5 months in 2022 at the Port Moresby General Hospital children's wards. Clinical information was gathered from the admission charts of children with life threatening and life limiting conditions and a recorded interview was carried out with the children's parents. A focus group interview with 10 experienced nurses caring for these children was video recorded. The recorded interviews were subjected to thematic analysis. RESULTS: Twenty children and their parents were included in this study. Nine had a cancer diagnosis and 11 had a chronic progressive condition. The common clinical characteristics of children with palliative care needs were pain (n = 9) and shortness of breath (n = 9), and most children had more than one symptom. Several themes were identified in the parent interviews. Most parents could not name their child's diagnosis, but they were able to correctly describe their child's condition using their own terms. Most parents felt involved in their child's management and were satisfied with the care provided. Parents were psychologically affected by their child's situation but were hopeful that God and the medicines would heal their child. Ten nurses were involved in a focus-group interview. Most nurses' understanding of palliative care was from experience not from formal training, but most felt confident in identifying the physical, emotional, and spiritual needs of the children. Understanding of analgesia was limited, as was the availability of appropriate medications included in the WHO Analgesic Ladder. CONCLUSION: There is a need for a systematic approach to palliative care in Papua New Guinea. Palliative care can be integrated into an overall approach to quality of paediatric care. It is relevant to a broad section of children with severe chronic or malignant conditions and can be carried out with limited resources. It does require some resources, further training and education, and increased provision of basic drugs for symptom control.

Rural healthcare workers views on the introduction of solar power and oxygen concentrators in health facilities in Papua New Guinea: a qualitative study.

INTRODUCTION: A motivated, well supported rural health workforce is required to provide appropriate child health services to the rural population. This study explored the views of rural health workers in Papua New Guinea on the impact of a program to improve oxygen delivery systems and to provide reliable power to their health facilities. METHODS: A pre-tested, self-administered open question survey was carried out among rural health workers from 38 health facilities in which oxygen concentrators had been installed, including 30 with solar power. Thematic analysis was carried out on the responses. RESULTS: The program was highly appreciated. Benefits extended beyond the ability to treat children with a reliable source of oxygen. Participants reported the positive community response to improved patient care and avoiding patient referrals. They stressed their wish for further improvements in infrastructure and for continuing education. CONCLUSION: The program improved morale and job satisfaction. The views of rural health workers are important in assessing program effectiveness.

Living with thalassaemia in Papua New Guinea, the experience of children, adolescents and their families.

AIM: Thalassaemia, the commonest genetic blood disorder in Papua New Guinea (PNG) presents daunting challenges for the affected children, their parents and families, and the health system. We aimed to describe the quality of life of affected children and adolescents and the experience of and difficulties faced by their parents in the setting of a tertiary referral hospital in PNG. METHODS: A mixed-methods longitudinal study involving baseline questionnaire, then serial interviews with parents, children and adolescents living with ß-thalassaemia attending Port Moresby General Hospital. RESULTS: Twenty-one patients and their families were interviewed over a 6-month period. Most families originated outside the National Capital District and had migrated to be near the Port Moresby General Hospital and its blood bank services. Thirteen patients had at least one affected sibling and four families had experienced the death of at least one other affected child. No child was receiving chelating agents, and most had clinical evidence of iron overload. There were important impacts of thalassemia on quality of life, including very poor school attendance and some aspects of children's self-perception. Families faced significant burdens and made genuine sacrifices to care for their children. CONCLUSION: Regular blood transfusions increase the life-span of children with thalassaemia but there is a need to achieve a hyper-transfusion regimen coupled with chelation therapy. As for all chronic illness, a focused and holistic approach is needed to improve the quality of life for affected children and their families.

Oxygen saturation reference ranges and factors affecting SpO2 among children living at altitude.

AIMS: To determine reference values for oxygen saturation (SpO2) among healthy children younger than 5 years living at moderately high altitude in Papua New Guinea and to determine other factors that influence oxygen saturation levels. METHODS: 266 well children living at 1810-2630 m above sea level were examined during immunisation clinic visits, and SpO2 was measured by pulse oximetry. Potential risk factors for hypoxaemia were recorded and analysed by multivariable analysis. RESULTS: The median SpO2 was 95% (IQR 93%-97%), with a normal range of 89%-99% (2.5-97.5 centiles). On multivariable analysis, younger children, children of parents who smoked, those asleep and babies carried in bilums, a traditional carry bag made of wool or string, had significantly lower SpO2. CONCLUSION: The reference range for healthy children living in the highlands of Papua New Guinea was established. Besides altitude, other factors are associated with lower SpO2. Some higher-risk infants (preterm, very low birth weight, recurrent acute lower respiratory infection or chronic respiratory problem) may be more prone to hypoxaemia if they have additive risk factors: if parents smoke or they are allowed to sleep a bilum, as their baseline oxygen saturation may be significantly lower, or their respiratory drive or respiratory function is impaired. These findings need further research to determine the clinical importance.

Oral Rehydration in Children with Acute Diarrhoea and Moderate Dehydration-Effectiveness of an ORS Tolerance Test.

Oral rehydration solution (ORS) is the mainstay of treatment of acute watery diarrhoea, but it is underutilized in many hospitals, resulting in children with moderate degrees of dehydration being unnecessarily hospitalized and receiving intravenous fluids. We aimed to assess the utility of an ORS tolerance test on initial presentation to an emergency department, and determine the volume of ORS a child with diarrhoea and moderate dehydration needed to tolerate to be successfully managed at home. One hundred and twenty-nine children with acute watery diarrhoea and moderate dehydration were given ORS and observed in a Children's Emergency Department (CED) over a period of 2-4 h. Patients were admitted, kept in the CED for further management or discharged, based on the assessment of oral intake and the clinical judgement of the treating health workers. Seventy-nine (61.2%) patients tolerated ORS well. They drank a median [interquartile range (IQR)] of 24.4 ml (IQR 12.5-28.8) ml/kg, were judged to have passed the ORS test and were discharged to continue oral rehydration treatment at home. At follow-up on days 2 and 5, 63/79 (79.7%) children had improved, were adequately hydrated and the diarrhoea had reduced. Sixteen of the 79 (20.3%) failed oral home treatment, with persisting diarrhoea, vomiting, hypokalaemia and/or weakness. The 63 who succeeded had tolerated a median of 25.8 (IQR 18.4-30.0) ml/kg of ORS in the CED, whilst the 16 who failed oral home treatment had tolerated 11.1 (IQR 9.1-23.0) ml/kg ORS (p < 0.001).

Safety, Effectiveness and Feasibility of Outpatient Management of Children with Pneumonia with Chest Indrawing at Port Moresby General Hospital, Papua New Guinea.

Implementing the World Health Organization (WHO) recommendations on home-based management of pneumonia with chest indrawing is challenging in many settings. In Papua New Guinea, 120 children presenting with the WHO definition of pneumonia were screened for danger signs, comorbidities and hypoxaemia using pulse oximetry; 117 were appropriate for home care. We taught mothers about danger signs and when to return, using structured teaching materials and a video. The children were given a single dose of intramuscular benzylpenicillin, then sent home on oral amoxicillin for 5 days, with follow-up at Days 2 and 6. During the course of treatment, five (4%) of the 117 children were admitted and 15 (13%) were lost to follow-up. There were no deaths. Treating children with pneumonia with chest indrawing but no danger signs is feasible as long as safeguards are in place-excluding high-risk patients, checking for danger signs and hypoxemia and providing education for mothers and follow-up.

Vitamin A status of pre-school-age children aged 6 to 59 months in the National Capital District, Papua New Guinea.

Assessing the vitamin A status among pre-school-age children is essential for evaluating the magnitude and public health status of vitamin A deficiency in a population. This cross-sectional study assessed the vitamin A status of children aged 6 to 59 months resident in the National Capital District (NCD), Papua New Guinea. Children attending the Children's Outpatient Clinic at Port Moresby General Hospital participated in this study. Informed consent was obtained from parents before using blood samples from their children. Assay of plasma retinol was carried out using the 'Clin-Rep' complete kit for assay of vitamins A and E in plasma by high performance liquid chromatography (HPLC). A commercial enzyme immunoassay kit was used to assay C-reactive protein (CRP) in plasma. Of the 132 children in the study 108 (82%) had received vitamin A capsules. The median plasma retinol concentration of the 132 children was 0.98 micromol/l and the interquartile range 0.65-1.38 micromol/l. Of the 132 children, 35 (27%) had a plasma retinol concentration below 0.70 micromol/l. 75 children (57%) had normal plasma CRP levels and in 57 (43%) the CRP levels were elevated. The median plasma retinol concentration of the children with normal plasma CRP was 1.19 micromol/l and the interquartile range 0.93-1.50 micromol/l. The prevalence of vitamin A deficiency (VAD) in the children with normal plasma CRP was 11%, indicating a moderate public health problem. 74 (56%) males and 58 (44%) females were included in the study. The prevalence of VAD in the male and female children with normal plasma CRP was 14% and 8%, respectively, indicating a moderate public health problem among the male children and a mild public health problem among the female children. The prevalence of subclinical (mild to moderate) and marginal VAD among the children with and without elevated CRP strongly suggests the need for continuous monitoring of the vitamin A status of the vulnerable groups in NCD.

The management of paediatric patients in a general Emergency Department in Papua New Guinea.

Children less than 13 years of age account for 27% of the case mix at the Emergency Department (ED) of the Port Moresby General Hospital (PMGH). The ED is busy, usually overcrowded, understaffed and under-equipped, resulting in less than optimal patient management. Children are a highly vulnerable group of patients and have the potential to deteriorate rapidly. This prospective descriptive study aimed to assess the adequacy of management of children presenting to the ED between 1600 and 0800 hours. A standardized and individually administered questionnaire was used to assess the management of 107 children. The median age was 13 months, interquartile range 6-36 months, with a male to female ratio of 1.5:1. The most frequent diagnoses were pneumonia/bronchiolitis, diarrhoea, malaria, asthma and febrile convulsions. Three-quarters of the sample were classified as being triage 1 and 2, ie, requiring either immediate life-saving treatment or treatment within 30 minutes to an hour of presentation. Median and interquartile ranges for time from arrival to assessment were 60 (15-110) minutes for triage 1, and 60 (30-121) minutes for triage 2 patients. Time from assessment to management was 5 (5-45) minutes for triage 1 and 40 (30-63) minutes for triage 2 patients. Treatment instituted was appropriate in 93% of cases but the drug dosage was incorrect in 26%. 49 children (46%) were admitted to the wards either directly or following further observation in the ED or Children's Outpatient Department, the rest being treated and discharged, except for one child with probable septicaemia who died following a prolonged and unattended wait in the ED. Management was assessed as adequate in only 40% of cases. The major causes of inadequate management were delayed treatment, under- or over-dosing, under- or over-treatment, omission of appropriate investigations, misdiagnosis and failure of judicious consultation with the paediatric team. Many patients were nursed on the floor. Recommendations emanating from the study include ensuring adequate staffing levels and the training of all staff working in ED in the rapid identification of sick children to improve triage and subsequent management.

Reference values for pulse oximetry in healthy children in coastal Papua New Guinea.

We expected oxygen saturation (SpO2) in children in coastal Papua New Guinea (PNG) to be higher than in PNG highlands children. Therefore, SpO2 was documented to determine the reference values of SpO2 in neonates and young children; 149 healthy neonates and 100 healthy infants and children < 5 years old were studied in Port Moresby. SpO2 ranged from 93% to 100% in both groups. The median SpO2 in neonates was 97% (CI 96.9-97.4) and in young children 98% (CI 97.5-98.0). We recommend 93% as the cutoff for administering oxygen to children under 5 years old in coastal PNG.

Early introduction of solids and pneumonia in young infants in Papua new Guinea: a case control study.

A prospective case control study to determine the association of early introduction of solids with admission to hospital with pneumonia was undertaken at Mount Hagen General Hospital (MHGH) in the highlands of Papua New Guinea (PNG) over a 3-month period in 2005. Twenty three infants up to 6 months of age admitted with radiologically confirmed pneumonia were compared with 24 infants of similar age attending the well baby clinic for immunization and with 35 infants admitted to the hospital with conditions other than pneumonia or meningitis. There was a highly significant difference in feeding patterns between the groups. Children with pneumonia were much more likely than the control children to have started solids before the age of 2 months [OR = 18.06 (4.8-72.86)]. They were also significantly more likely to have been admitted previously with a diagnosis of pneumonia (P < 0.001). The children in each group were of comparable age and weight and there were no obvious confounding factors. This study provides clear evidence for the association between early introduction of solids and pneumonia in PNG highlands children. The findings are consistent with other international data. While the reasons for the association remain speculative, the association strongly reinforces the need to educate the community on best infant feeding practices and to discourage the early introduction of solids.

Thirty years of the Paediatric Standard Treatment Book.

The publication of the 8th edition of the Paediatric Standard Treatment Book 30 years after the first edition was introduced in 1975 provided an opportunity to examine the changes in the book's content and composition that have occurred over time. A detailed analysis of all editions of the book was made. The 8th edition is bigger, contains more clinical and guidance topics, and is undoubtedly more complex than the first. Health workers of different levels of training undoubtedly value the book, but there is evidence that it is frequently not used appropriately. The books form an important historical record of the changes in treatment of various clinical conditions that have been driven by alterations in antimicrobial susceptibility and by the emergence of evidence for efficacy. The current book is intricately linked with the Integrated Management of Childhood Illness and the treatments it contains are based on best evidence and practicality. Whilst there are challenges in ensuring that the information in the standard treatment book is accessible, practical and up to date, the book will continue to provide the basis for treatment of the common conditions presenting in children in the future.

Neonatal outcome at Modilon Hospital, Madang: a 5-year review.

An audit of neonatal care at Modilon Hospital, Madang was performed using obstetric and neonatal data for the five years 1995-1999. The overall perinatal mortality rate (PNMR) was 51.1 per 1000 total births with an early neonatal mortality rate (ENNMR) of 12.7 and a stillbirth rate (SBR) of 38.5. 839 neonates aged 0-28 days were admitted to the Special Care Nursery. The male to female ratio was 1.3:1. 186 babies (22%) died. The case fatality rate was higher in males than females (p<0.001). Babies born at health centres or born before arrival had a significantly higher fatality rate than hospital-born babies (p<0.001). The case fatality rate was highest in babies born preterm and declined with increasing birthweight from less than 1000 to 3999 g. The major recorded causes of admission were neonatal sepsis, prematurity, neonatal jaundice, birth asphyxia, respiratory distress and meconium aspiration syndrome. 60% of deaths occurred within 48 hours of admission, 32% between 48 hours and 7 days and 8% at 7 days or older. The proportion of deaths occurring during the afternoon and night shifts was significantly higher than that during the morning shift (p<0.001). This was most likely to be related to staffing levels. The major causes of death were prematurity or low birthweight (27%), sepsis (23%) and birth asphyxia (17%). Other causes of death included congenital abnormalities, meconium aspiration and meningitis. Antenatal care is still not universally available for Papua New Guinean women. Home delivery of high-risk mothers is commonplace, and women delivering in hospital often present in established labour. Perinatal and neonatal problems are therefore frequent. Newborn babies have the right to the best available care. This can only be provided if hospitals and health facilities understand the basic requirements of neonatal care and provide designated space, adequate staffing and proper equipment.

Mortality in children admitted to Port Moresby General Hospital: how can we improve our hospital outcomes?

A detailed audit, part retrospective and part prospective, of deaths occurring in children admitted to the children's wards of the Port Moresby General Hospital over a 12-month period was made. 238 children died out of the 4898 admitted, an overall case fatality rate of 4.9%, with a monthly range of 3.7%-9.6%. The proportion of deaths approximated the proportion of admissions in each age group. 92% of the children had a weight of less than 80% of the standard weight for age and 30% weighed less than 60% of the standard weight for age. 24 (11%) of the deaths occurred within the first 6 hours of admission, 39 (17%) within the first 12 hours and 58 (26%) within the first 24 hours. 89 children (40%) died more than one week after admission. Pneumonia, meningitis, measles and septicaemia were the four leading certified causes of death and paediatric AIDS was the fifth. Less than half of the deceased children were appropriately immunized for their age. 27 deaths (12%) were assessed as preventable. 150 (67%) were classified as from treatable causes but unavoidable, 18 (8%) from untreatable causes, 22 (10%) of undetermined cause and 34 (15%) avoidable. The factors associated with avoidable deaths were delayed treatment (20 children), inadequate treatment (8 children), incorrect treatment (1 child) and others (5 children). Infant and child mortality could be reduced by general measures such as improving community nutrition and immunization status and improving care-seeking behaviour. Hospital-related measures to reduce mortality include improving the accuracy and effectiveness of triage and provision of adequate staffing levels and bed space. Periodic in-depth audit is necessary to assess quality of patient care, to identify problems and to point towards their solution. Accurate recordkeeping is essential for appropriate audit and planning.